Sunday, April 8, 2007

NMO Treatment

Again, NMO typically lacks secondary progression and therapy is designed to address acute attacks and limit destruction thereof. For acute attacks, an initial course of Solumedrol is standard consisting of 5-7 days of treatment. Refractory cases are often highly responsive to plasma exchange. Weinshenker studied exchange v. sham exchange in a group of patients with neurologic disease many of whom had NMO, and 42 % responded. His protocol is seven phereses QOD over 14 days. For attack prevention, standard MS therapies are ineffective. Standard immunosuppression consists of a combination of azathioprine and prednisone. As in other neurologic diseases, azathioprine has a long latency to effect and relapses can occur in the interinm that are prevented with prednisone. Mycophenolate can be substituted for azathioprine, but cannot be titrated based on MCV and WBC making it a blind therapy. Frohmann's IV MTX case used 2.5 gram / meter squared wiuth leukovorin rescue. Rituximab is an anti CD20 MAB that eliminates pre B and mature B cells. 4 weekly infusions each involving 375 mg/m(2); 7/8 had had breakthrough disease and 6/8 remained relapse free with an EDSS improvement from mean 7.5 to 5.5. After B Cell recovery 2 more infusions of 1000 mg 2 weeks apart are given. Mmitoxantrone is also an option. The protocol in theonly study done was changed to give more MTX upfront, due to patients relapsing early if every 3 month therapy was chosen. IVIG stabilized 2 patients with active disease despite azathioprine and steroid therapy